Listen to this story
“The good physician treats the disease; the great physician treats the patient who has the disease.” -William Osler
Physician heal thyself
Medicine is a tough profession. It’s both tremendously rewarding and terribly demanding. I love being a doctor. I love helping people with their toughest problems. But I can’t stand what medicine is becoming.
State of the union
For many doctors, healing isn’t just a job — it’s a calling. Along with a handful of other professions, doctors are privy to the most sacred and difficult aspects of human existence. We share in the joys and triumphs of illness. We witness the grief, horror, beauty, peace, and love that occur when people succumb to terrible diseases we have no way of effectively fighting or preventing, let alone understanding. Physicians are at the front lines of humanity, along with other warriors like nurses, PAs, first responders, therapists, human rights workers, military personnel, clergy, and more.
But being at the front lines can take a toll: In 2012, a study showed that physicians reported much higher work-life dissatisfaction compared to the general population. Within that study, 40.2 percent of physicians reported dissatisfaction versus 23.2 percent of non-physicians. The same study found that burnout rates were high across the board for physicians as well, with nearly 50 percent of doctors reporting that they were burned out. Emergency room doctors have it the worst, with nearly 70 percent reporting burnout, followed closely by physicians working in general internal medicine, neurology, family medicine, and a host of other demanding subspecialties. General pediatrics, dermatology, and preventive, occupational and environmental medicine practitioners reported the lowest burnout rates, just short of 30 percent.
According to a 2015 Mayo Clinic survey, this situation is not improving any time soon. Of the nearly 36,000 physicians who were contacted, 6,880 responded to an invitation to participate in a study of burnout. Results showed that these doctors became more burned out over time: 54.4 percent reported at least one symptom of burnout in 2014, up from 45.5 percent in 2011. Likewise, average work-life satisfaction ratings dropped from 48.5 percent to 40.9 percent in the same three-year time frame. Compared to the average U.S. citizen, physicians are much more likely to experience burnout and much less likely to enjoy work-life satisfaction.
Studies about physician burnout and stress are important but they typically don’t reflect this group’s high risk for even more dire mental health outcomes, like suicide. In a recent The Lancet Psychiatry review and meta-analysis, Katherine Petrie and her fellow authors reported that in addition to burnout, physicians also demonstrate a high risk for other depressive symptoms, like anxiety and suicidal thinking. Past research has also shown that physicians have a higher risk for suicide compared with other professions, ranking in the top ten of risky professions. And Petrie’s study noted that while other occupational groups have high rates of difficult mental health symptoms, physicians are more likely to die by suicide. Chillingly, the study noted that one physician dies from suicide every day in the U.S.
On a personal note, I’d like to add that when a physician commits suicide, it rocks the whole community. Health care systems respond with wellness meetings and other interventions but in my experience, trainees still report feeling uncared for and skeptical of administrative responses. I often hear that it’s not only “too little, too late.” It’s also that trainees believe their higher ups really don’t care to address systemic issues. These new physicians often consider wellness programs to be lip service, alongside efforts to control hours. In fact, several trainees anecdotally confided in me that they are told to report fewer hours than they actually work in order to meet regulatory requirements. They often say that doing the paperwork and making sure the business of medicine runs well takes precedence over care, and they bemoan a lack of adequate training and educational opportunities. Some of these complaints may be the voice of burnout, disillusionment, fatigue and cynicism, which can obscure the real, positive aspects of our work when an opportunity to vent arises. But nevertheless, these comments must be taken with the utmost seriousness. Trainees typically do not feel heard.
The Lancet study authors highlighted similar concerns to those I’ve heard, reporting that workplace factors contribute to physician suicide “including a large workload, long and irregular working hours, competitiveness of training programs, pressure of patient and service demands, the consequences of any errors, poor work–life balance, and the risk of moral injury if physicians are forced to work in ways that conflict with their ethics and values.” The authors note that the culture of medicine itself contributes to mental health problems, preventing physicians from seeking help because of factors like the stigma against mental health problems, burdensome regulatory practices, and concerns about being able to seek care for oneself due to confidentiality.
I can tell you, again from personal experience both as a surgical resident and also as a psychiatrist, that medical training is rough and at times, abusive. It emphasizes stoicism. Despite positive changes in recent years, including some medical training programs that really do encourage openness and help-seeking, we are still haunted by stigmatizing labels. For this reason, revealing your need for help can be a risky business, as it can inspire comments about being weak, letting your team down, or not being able to “take it.” If this kind of behavior comes from colleagues, or even worse from someone who has the power to control your career, it can be extremely detrimental. I’ve been on both sides of that dynamic.
According to The Lancet authors, despite growing research on burnout in medicine, there is little attention given to both the presence of diagnosable mental health issues or interventions that could prevent and treat mental health issues like suicidal ideation. In order to better advance the current state of understanding, the authors of this study set out to conduct a literature review and meta-analysis of the existing research on physician mental health. After culling through major databases and reviewing thousands of published papers for eligibility, they found only a handful of well-designed studies investigating physicians and potential mental health-related interventions and outcomes. The vast majority of the studies excluded were ineligible due to methodological issues, a lack of attention to the core issues of interest, and the inclusion of groups other than physicians. Of course, it’s no mean feat to conduct a good study around these issues. It can be hard to assess a very large and complex set of data, as well as to distinguish causation from correlation. But the big question we need to answer is this: Is being in the field of medicine the cause of mental health problems or would they have happened anyway?
Why the research isn’t there
The Lancet review found two main things: Strikingly, there is very little quality research about physician mental health and suicide. Despite decades of research on burnout and stress, there has been little attention paid to the hardcore issues of depression, anxiety, suicide and related issues. In my professional life, I have experienced this blockade first-hand: Early in my career, I was asked to participate in a physician wellness study. For the study, I was asked to stay on call, just in case they found any residents who needed psychiatric care immediately. I also recommended that they study depression and suicide risk as part of their survey. After I made that comment, I didn’t get a call back and I was not invited to participate in the study; they just stopped responding to emails.
The Lancet authors also found something else of interest: Interventions for physicians can be effective when they’re available. They looked at both individual and group interventions and found that they were moderately effective at reducing symptoms of depression, general mental distress, anxiety and suicidal thinking in physicians. (Evidence for the latter two, however, only came from one study.)
The quality of the data, even in the best studies, was poor. This demonstrates, yet again, the systemic stigma against knowing what’s going on with physicians when it comes to mental health and suicide. For instance, The Lancet authors found that every study about physician mental health relied on self-reported data. None of the studies included formal diagnostic measures or clinical evaluations (which is the standard in related research on non-physicians). The Lancet study revealed that several interventions, mainly cognitive-behavioral and mindfulness-based, reduced self-reported symptom burdens. However, they were unable to show that these interventions prevented depression or suicide. The research simply wasn’t there to review because it hasn’t been done.
Remarkably, there were no studies at all about the organizational interventions that have been known to help people in other fields, like the “rescheduling of work hours, reducing workloads, and modifying local working conditions.” As I noted anecdotally above, systemic responses to physician suicides are typically reactive. There are healthcare system-wide meetings, spot interventions for colleagues directly affected, and recommendations given to individuals who should seek treatment with a therapist. However, here are no studies (yet) that look at whether organizational interventions could actually prevent physician suicides in the first place. From my perspective, there are only emerging efforts on the part of organizations to take a closer look at this troubling and easily shunned area of the medical system.
The take home
This new meta-analysis published in The Lancet is a major milestone for understanding and appropriately responding to the mental health crisis facing medicine today. The research is startlingly scant, perhaps unforgivably. Rather than dwelling on the past, the alarm has now been sounded: Greater attention must be paid to physician well-being. We need better research that uses clear diagnostic measures and evidence-based interventions, on a large scale.
We need to look at interventions and preventive measures directed at individuals and groups, and we need to focus on systemic and organizational interventions that could change the very culture of medicine. We need to not only put new programs into place, but also take a deep dive into the culture of medicine itself to understand why a field devoted to caring for others is unable to properly care for itself. We want physicians to be safe and well, but we also need to help those we serve by modeling good health practices. When we fail to do this work, we let down not only ourselves, but also our patients and society.
Fortunately, research studies like this are already underway. Soon, we will hopefully be able to better address part of what is missing in the current conversation about physician mental health. And medicine is also changing, albeit seemingly too slowly at times, for the better. It’s important that physicians continue to take a stand, not just about research and policies but also on the ground, in the wards, on Grand Rounds, in the classrooms, and in lecture halls.
Originally published at www.psychologytoday.com